A public health merger in Chicago?

Health care experts and some public officials are floating a radical idea as Mayor-elect Rahm Emanuel prepares to take office: a full or partial merger of Chicago and Cook County's health departments.

Operating a single health department with broader responsibilities could improve the delivery of services and create administrative efficiencies in budget-strapped times, they suggest. That is the way things are organized in Los Angeles; Miami; Seattle; Nashville Tenn.; Oklahoma City; Portland, Ore.; and several other sizeable metropolitan areas.

"I think this is something that definitely needs to be seriously looked at by both sides," said Dr. Terry Mason, interim chief executive of the Cook County Health and Hospitals System and former commissioner of the Chicago Department of Public Health.

Chicago officials declined comment, but a report this week from Emanuel's transition team noted the desirability of collaborations and the need for a stronger public health agenda for the city.

Supporters hope Emanuel and Cook County Board President Toni Preckwinkle will consider the proposal as they explore new ways for the city and county to work together.

Critics, including unions apprehensive about losing jobs, worry that a merger could become an excuse for cutting budgets or privatizing certain functions.

Under a merger, some or all of these services could be combined under a single administrative structure, potentially eliminating duplication.

A merger could involve just the Cook County Department of Public Health, which operates only in suburban Cook, or the entire Cook County health system, which includes Stroger Hospital and other operations in the city and suburbs.

"We need to take an inventory of all the things that the city and the county do and see if there are synergies," Mason said.

For instance, the city's medical clinics could be combined with Cook County's much more extensive clinical network, which includes primary care centers, specialty medical services and advanced care at Stroger Hospital. Providing medical care is a "core competency" for Cook County but less so for the city, Mason acknowledged.

Chicago-area residents could benefit if the current fragmented system was replaced by a more coordinated approach to public health, suggested Stephen Martin, chief operating officer for the Cook County health department.

For example, two years ago, amid the scare over so-called bird flu, many people who live in the suburbs but work in the city were confused when they heard that clinics had received vaccines and were ready to give flu shots. Though this was true in the city, the vaccines were not yet available in the suburbs and people were upset over what they considered bad information, Martin said.

Similarly, it's common for investigations into cases of communicable disease, such as tuberculosis, to start in Cook County but cross into Chicago when investigators learn that an infected person's contacts reside in the city. Under the existing setup, each area's health department conducts disease investigations separately. But with constant traffic between the city and the suburbs, that process is cumbersome and inefficient, Martin argues.

"Diseases don't care about county or city boundaries," he said.

Next week, Martin's department plans to formally recommend to a committee of the Cook County health system that a blue-ribbon panel explore the feasibility of consolidating the two public health departments. Separately, Chicago's Health & Medicine Policy Research Group, a private policy organization, is preparing to recommend that the city and the county consider creating one system that would help protect the health of vulnerable populations, according to executive director Margie Schaps.

Any changes proposed are likely to run into political opposition from officials worried about losing control of public health and unions worried about losing jobs.

"We are concerned about what this might mean," said Anne Irving, director of public policy for the American Federation of State, County and Municipal Employees Council 31. "We could end up with a system that does not have the access to services that we currently have, and that would be bad for our communities."

Several years ago, Sister Sheila Lyne, former commissioner of Chicago's Department of Public Health and now president of Mercy Hospital & Medical Center, said she would have opposed consolidating any functions with Cook County. "It was my department and I wouldn't have wanted to lose anything in it," she said.

Today, however, given budget strains affecting all levels of government, and public health crises like the obesity epidemic, Lyne said she sees some sense in a combination. "Putting together things like immunizations, prenatal and postnatal care, the clinics, HIV/AIDS, I do think that's possible," she said.

For example, financial constraints have reduced Cook County's contribution to its health system's budget to $273.4 million in the current fiscal year from $410.8 million the year before. (Most of the system's funds come from the federal government and the state.) In response, the system has eliminated almost 1,350 jobs.

Lyne also said she worries about health officials becoming preoccupied by the mechanics of a merger and losing focus on the extensive medical needs of some Chicago communities.

With the recent unexpected resignation of its chief executive and a controversial new strategic plan yet to be fully implemented, Cook County's Health and Hospitals System already has an enormous amount on its plate and caution is in order, said Dr. David Ansell, a member of the system's independent board of directors.

Consolidating certain parts of the Chicago and Cook County health systems isn't an entirely new idea; discussions were first held more than 20 years ago. But "what was missing was the political will and the financial necessity to move ahead. I think now we have both," said Patrick Lenihan, executive director of the Public Health Institute of Metropolitan Chicago.

Across the country, several other cities and counties are looking at similar arrangements, for similar reasons. Elsewhere in Illinois, the city of Springfield and Sangamon County recently combined public health functions. In St. Louis, a full merger of the city and county is being explored and generating considerable controversy.

In addition to financial considerations, discussions are being motivated by new opportunities and challenges presented by national health reform. In this region, hundreds of thousands of needy people will become newly eligible for government coverage in 2014. What role the city and county clinics will play in providing care to this population is yet to be determined, said Dr. Lee Francis, president of Erie Family Health Center.

Meanwhile, many of the area's undocumented immigrants will remain uninsured, posing an ongoing challenge, noted Richard Sewell, associate dean of community and public health practice at the University of Illinois at Chicago School of Public Health. Increasingly, uninsured immigrants and deep pockets of poverty are found in Cook County's suburbs as well as in the city.

What's clear, Sewell said, is that "if Emanuel and Preckwinkle want something to happen, it will. I think it would be elegant and we would have better services. But nothing is going to move ahead without their leadership," and neither has made his or her position on the matter known.